Author: Duncan Stevenson (Graphic Designer)

#Safer Epidurals
Sophie Moran and Carol Burrows

Background and problem
For patients receiving epidural analgesia, treatment dose low molecular weight heparin (LMWH) such as Fragmin, and oral antiplatelets (Rivaroxaban, Dabigatran, Apixaban) and oral anticoagulants (Clopidogrel) are contraindicated as they increase the risk of epidural haematoma formation (The Association of Anaesthetists of Great Britain).
Over a 12 month period (April 2018-April 2019) there were 5 Datix incidents involving either treatment dose LMWH or oral anticoagulants, antiplatelets other than aspirin being administered or prescribed to patients with an epidural in situ. Several of these were in vascular patients.
A literature search was conducted which showed that research was lacking in this area, although it showed that there was an elevated risk of haematoma development in patients with abnormal coagulation parameters (1 in 315 patients Gulur et al. 2015), the risk was not deemed sufficient to cease epidurals in this patient cohort.
This highlights the importance of monitoring this patient group and clear documentation of rationale for deviation from The Association of Anaesthetists of Great Britain guidance.
2. Aim
To improve compliance with documentation around anticoagulant/antiplatelet medication, in patients with epidural analgesia by 50% over a 6 month period.
3. Method
Prospective audit of compliance meeting 4 criteria (epidural alert sticker on front of drug chart, safe dose of thromboprophylactic low molecular weight heparin (LMWH) prescribed, epidural alert magnet visible above bed, plan documented in notes for recommencing oral anticoagulants/antiplatelets) undertaken for 10 consecutive vascular patients receiving epidural analgesia.
Location: vascular ward June-December 2019
Engagement: Discussion with key stake holders: vascular consultants, vascular ANPs, pharmacy, anaesthetics, anaesthetic nurses/ODPs and ward staff.
PDSA cycles:

Primary drivers
-Increase compliance with visual alerts
-Reduce risk of oral anticoagulants/antiplatelets being given concurrently whilst epidural in situ eg. Clopidogrel, Rivoroxaban and Apixaban
-Improve awareness and communication of safe management of epidurals
- Ensure written plan in place if treatment dose of Fragmin prescribed or Heparin infusion

Secondary drivers
-Epidural sticker on front of drug chart
-Inclusion of epidural during anaesthetic WHO (STOP before you block checklist)- clear plan for post operative anticoagulation.
-Aide memoire for surgical doctors
-Increase junior doctors and nurses awareness of safe doses of LWMH and need to cease oral anticoagulants/antiplatelets while epidural in situ.

4. Results
Baseline results obtained prior to project showed
poor compliance with the magnet behind patients
bedside and distinct lack of plan around restarting
Anticoagulants/platelets.
Initially compliance with the visual alert of a sticker
on patients medication chart and safe dose of
Fragmin was good, at 60%
Cycle 1: After introduction of STOP before you block improvements noted in application of sticker and safe Fragmin dose.
Cycle 2: After teaching of the F1’s on the vascular ward improvements noted in all 4 criteria.
Cycle 3: Teaching of ward base nursing staff showed a reduction of use of magnet which was disappointing. However, there was a marked improvement of a documented plan in the medical notes. This could have been an anomaly or as a result of the previous teaching and awareness.
Overall compliance with documentation around safer epidurals and anticoagulant/platelet medication improved by 40% not the 50% target.

Next steps
-Incorporation of discussion of anticoagulants/ antiplatelets and epidural during doctors ward round to maintain improvements by vascular team.
-Inclusion of epidural discussion during the anaesthetic WHO
- Incorporate awareness and teaching in Acute Pain Study days for nursing staff regarding use of the epidural magnet.
-Liaise with the vascular nurse specialist to incorporate safer antigoagulation and epidurals in the Vascular doctors induction.
- Include advice around anticoagulants etc in the Acute pain session for trainee anaesthetists induction.